Urinary Tract Infections in Women: Stigma and Misunderstanding

Back in November of 2022, I returned to campus from fall break, drinking two bottles of water every couple of  hours. I worried I would not make it through the short plane ride back without needing a bathroom. Something felt wrong. 

My first stop upon reaching campus late on Tuesday night was the bathroom. I felt a burning pain sensation radiating from my pelvis area. I instinctively and frantically called my mom:  "I think I have a UTI, it hurts so bad, what do I do?”

A urinary tract infection (UTI)  occurs when the urinary tract becomes infected with a bacteria that the body can’t “flush out” on its own. They are the most common outpatient infection in the United States[1]. They affect both men and women, but more commonly impact those with uteruses – those with longer urinary tracts and urethra that are anatomically close to other systems.  About 50- 60% of women will report having  a UTI in their lifetime and 27% of those will recur at least once after the first time[2]. I surveyed local students at Barnard College in New York City through a Biology student Listserv and my social media and found that 46% of respondents in this convenience had contracted a UTI before. Despite their prevalence in women of all ages, these infections still seem to be uncharted territory in the way they are handled at the doctor. 

The next day after class I went to student health services and begged them to see me. I consulted with a Nurse Practitioner, let’s call her Clara, later that afternoon. I left with a prescribed bottle of antibiotics; I indeed had a urinary tract infection, and with this medication, I felt confident that the end of my pain was in sight. I woke up the next morning feeling like a new woman, no longer in pain. I got lots of advice from friends, family and the internet about how to prevent or treat my UTI at home:  informal cultural practices about them are diverse, whether they are recommendations to drink water or cranberry juice.  I was glad that the antibiotics had done the trick, but I wondered what truth there was in the suggestions I had read about.  I made sure to drink enough water and cranberry juice[3], which are known to help prevent UTIs. My research revealed that there is something specific about the cranberry that helps prevent infections. This review concluded that a cranberry supplement when compared to a placebo on nonpregnant women who have previously had an infection, reduced the risk of recurrent UTI by 26%[3]. 

These common infections can be contracted in many different ways and can present differently in everyone. Typically, increasing frequency and urgency of urination and dysuria (painful burning sensation) and abdominal pain are the tell tale signs but other symptoms include cloudy urine, fatigue and vaginal irritation[6]. UTI occurs when unwanted bacteria find their way into the urethra or other areas of the urinary system[6].  While the urethra and by association the women, often get the blame for starting an infection--bacteria can set up camp anywhere in the  system. There are ways for bacteria to colonize in our gut through what we eat and are exposed to[7]. The urinary tract is composed of the kidneys, ureters, bladder and urethra. The farther up the infection expands the risks for severe symptoms and may require more serious treatment[8]. UTIs typically begin in the lower tract however, if gone unnoticed and untreated, can spread into the bladder and kidneys. The farther into your body the bacteria travel, the longer and more serious the symptoms become. If you have never gotten a UTI before, know that pink urine is something to check for. Pink, as a result of red blood cells from somewhere in the tract finding their way into your urine, is a sign that the infection has progressed to the bladder and/or kidneys[9]. Kidney infections are serious business, symptoms include pink urine, fever, and back pain[6]. 
 

Many may be wondering how this happens:  How do we contract UTI? There are thousands of colonies of bacteria that are in your body and reproductive tract especially due to normal functions such as going to the bathroom. Common bacteria that we need to sustain a healthy gut and external environment and immune system like E. Coli live in our bowels and sensitive skin[7][17]. There are a couple of ways that this bacteria can make its way into our urinary system. Differences in anatomy between men and women lead to women having much higher rates of developing these infections[8].  The close proximity of the urethra opening, vagina and anus are all common causes of UTI in women[6].  Living in the same neighborhood means that cross contamination happens between each system. The urinary, reproductive and digestive system all have a baseline colony of bacteria needed to keep systems healthy and functioning but when the ratio of good to bad bacteria gets disrupted by other systems, the urinary system starts to malfunction. Due to this, having sex, poor hygiene, working out, previous use of oral antibiotics, and a catheter are thought to be common links to these infections[6].

For medical diagnosis, urine needs to be tested, even if it is inconvenient to have to go into the office given scheduling is a hassle. During the many times that I have had  to be seen for my symptoms over the last couple years, I felt confident that I was experiencing a UTI but I still had to go in person to receive a prescription. I'm sure many others have had this issue, but as a physician or practitioner, they need to test your urine for nitrites and leukocytes (white blood cells are signs of infection) as well as the type of bacteria that is causing the infection[6]. 

When I was in the office the first time I received my UTI diagnosis, the nurse asked me a bunch of questions. When did the symptoms start? What is the pain on a scale of 1-10? Any fever or chills? Then came the more awkward line of questioning. Have you been sexually active recently? This last one, I was expecting because I  knew that intercourse is one risk factor for UTIs.  Then she asked me  how many partners I had had. This question threw me. Why was that any of her business?  Why did that matter?  I felt embarrassed even though I had only been with one person and I felt like she was blaming me.  What I wished I had known and what I wish she had told me is that sometimes you can do everything right and still get sick. 

It seems that anything having to do with sex is embarrassing, even though it really shouldn’t be, since it is an evolutionary mechanism crucial for our survival as a species. In the survey I conducted, of college students, of the 28 students who reported that they had  a UTI, 9 (32%) said that they were embarrassed to go to the doctor.  Part of this may have been because of their interactions with their health care providers:  Many of the respondents mentioned that they were told they had poor hygiene and it was essentially their fault if their the UTIs came back,  even though recurrent UTI are common (in general country wide surveys,  20% will have a recurrence, or chronic UTI [10]. For my student population survey, 29% have been diagnosed with a recurrent UTI). 

Recurrent UTIs are not the only complication of initial infections.  For me, and for many people who are taking antibiotics, a yeast infection can crop up after the antibiotics and wipe out all the bacteria in your urinary system and surrounding areas[11]. In particular, broad spectrum antibiotics that kill a range of bacteria can lead to overgrowth of yeast yet another type of treatment, to help your body be able to recolonize the healthy bacteria in your reproductive and urinary systems[11]. In my  survey of college students,  1 in 5 had to use an antifungal treatment for a yeast infection after a UTI.  The solution that worked for me was a cream to fix the itching that was a result of the antibiotics. 

Subsequent infections, and a course of treatment increases the risk for developing additional infections[12]. In a recent study by Washington University School of Medicine researchers, scientists  infected mice with E. coli, the most common bacteria in diagnosed UTIs, treated them with antibiotics, and then re-infected them after a month. The mice that successfully cleared the infection the first time had significantly quicker and more effective immune responses upon re-infection, managing to eliminate the bacteria even faster than before. However, the mice that failed to clear the infection initially struggled upon re-infection, despite mounting a rapid immune response. Many of them ended up with chronic infections[12]. Researchers, and subsequent animal modeling,  suggest that this may be caused by lingering damage, epigenetic changes and inflammation in the bladder that may take a long time to recover from in mice, and potentially humans. 

Using these results  as background, the same group dove into the molecular microbiome of the urinary tract before and after an infection with E. Coli. There are urothelial stem cells that regenerate during and after an infection to propagate the system with healthy cells[13]. They looked at the epigenetic programing of these cells after an initial infection and found that there was DNA modification and chromatin molecular imprinting that heightened the immune response to subsequent infections[13]. These new cells were primed to have a quicker response and inflammation markers to get rid of the infected cells. Many of the genes that are associated with mucosal bladder lining inflammation and tissue wounding showed increased expression showing that the microbiome of the bladder and urinary tract has changed since the first infection. This is crucial information and will hopefully help progress our understanding with recurrent UTI infections and how best to prevent and treat them[13]. 

Getting a UTI for any reason should not be embarrassing. Risk factors are common, and simple antibiotic prescriptions do the trick in easing pain. Don’t be apprehensive to visit your doctor to receive a diagnosis and receive treatment for your symptoms. This is an issue  that women commonly deal with due to their unique anatomy and/or other causes. It is important we feel comfortable seeking care, safely and without judgment.